Individual/Family Insurance Quotes

Group Disability Insurance

Long-Term Disability (LTD)

In the event that an accident or illness prevents an employee from
working for an extended period of time, the financial impact can
be severe for the employee and employers. Long Term Disability (LTD)
protection is designed to help cover the employee's expenses while
their regular income is interrupted. Flexible plan design options
and benefit alternatives are available to meet specific needs. This
valuable protection is available with low-cost, tax-deductible premiums.

Short-Term Disability (STD)

A steady income is essential for most people. If an accident or
illness interrupts that income, it affects both the employee and
employer. Short Term Disability (STD) protection is designed to replace
a portion of the wages lost when a short term disability occurs.
An affordable, flexible STD plan can provide needed benefits to both
the employer and employee.

Group Disability Insurance Quote Request

Please take a moment to fill out the form below and one of our local insurance agents will contact you with a free, no-obligation quote. This information will be kept confidential and will be used for quote purposes only.

* Required fields.

General Information

Legal Name of Business:

Contact Name: *

Address:

City:

State:

Zip:

Business Phone: *

Fax:

Best Time To Call:

AM
PM

E-mail Address: *

Type of Business

Type of Business:

No. of Full Time Employees:

No. of Part Time Employees:

Give a complete description of any type of hazardous/dangerous
duties performed by your employees:

Current Group Health
Insurance Information

Carrier (Company) Name (not agency):

Policy Expiration Date:

Premium Amt: $

Years Insured:

Please give a brief description
of your current Group Health plan:

Benefits Desired

Major Medical
Deductible:

Optional
Pregnancy Coverage:

Yes
No

Dental Coverage:

Yes
No

Supplemental
Accident Coverage:

Yes
No

Disability Insurance:

Yes
No

PCS Card:
(Prescription Disc Option)

Yes
No

Group Life Insurance:

Yes
No

PPO Option:

Yes
No

Amount:

$

HMO Option:

Yes
No

Employee Information

Please list all employees you wish to cover:

Employee Name

Job Title

Date of Birth

Salary

Sex

Dependent Status

Male
Fem

Male
Fem

Male
Fem

Male
Fem

Male
Fem

Male
Fem

Male
Fem

Male
Fem

Male
Fem

Male
Fem

Male
Fem

Male
Fem

Male
Fem

Male
Fem

Male
Fem

If you were not able to list all employees
you wish to cover in the spaces above,
please use the Additional Comments section below
or indicate that you will fax or e-mail an additional listing.

Additional Comments
or Questions

Enter Security Code:

Please click the "Submit Quote Request" button
to send your quote request. No coverage is in effect
until bound by an insurance carrier. This is a request
for quotation only.